{"id":702,"date":"2017-06-02T22:43:06","date_gmt":"2017-06-03T03:43:06","guid":{"rendered":"https:\/\/www.brycepublications.com\/RCB\/?page_id=702"},"modified":"2017-06-02T22:43:06","modified_gmt":"2017-06-03T03:43:06","slug":"recipient-application","status":"publish","type":"page","link":"https:\/\/brycepublications.com\/index.php\/recipient-application\/","title":{"rendered":"Recipient Application"},"content":{"rendered":"<div id=\"pl-702\"  class=\"panel-layout\" ><div id=\"pg-702-0\"  class=\"panel-grid panel-has-style\" ><div style=\"padding: 25px 0; \" data-overlay=\"true\" data-overlay-color=\"#000000\" class=\"panel-row-style panel-row-style-for-702-0\" ><div id=\"pgc-702-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-702-0-0-0\" class=\"so-panel widget widget_sow-headline panel-first-child\" data-index=\"0\" ><div style=\"text-align: left;\" data-title-color=\"#443f3f\" data-headings-color=\"#440505\" class=\"panel-widget-style panel-widget-style-for-702-0-0-0\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-headline so-widget-sow-headline-default-218a574a0718-702\"\n\t\t\t\n\t\t><div class=\"sow-headline-container \">\n\t\t\t\t\t\t\t<h1 class=\"sow-headline\">\n\t\t\t\t\t\tDonation Program Recipient Application\t\t\t\t\t\t<\/h1>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"decoration\">\n\t\t\t\t\t\t<div class=\"decoration-inside\"><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n<\/div><\/div><\/div><div id=\"panel-702-0-0-1\" class=\"so-panel widget widget_black-studio-tinymce widget_black_studio_tinymce panel-last-child\" data-index=\"1\" ><div style=\"text-align: left;\" data-title-color=\"#443f3f\" data-headings-color=\"#443f3f\" class=\"panel-widget-style panel-widget-style-for-702-0-0-1\" ><div class=\"textwidget\"><p><span style=\"font-size: 20px;\">Recipient Application:<strong> &nbsp;<\/strong><\/span><\/p>\n<p>&nbsp;<\/p>\n<p><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_10_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_4kfbc\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">Recipient Application Request<\/legend>\n\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"10\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_10\" id=\"frm_hide_fields_10\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"4kfbc\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_10\" name=\"frm_submit_entry_10\" value=\"2b857dd469\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/702\" \/><div id=\"frm_field_106_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\">Contact Information<\/h3>\n\n\n<div id=\"frm_field_108_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n    <label for=\"field_k8ia\" class=\"frm_primary_label\">Name\n        <span class=\"frm_required\">*<\/span>\n    <\/label>\n    <input type=\"text\" id=\"field_k8ia\" name=\"item_meta[108]\" value=\"\"  data-sectionid=\"106\" style=\"width:300px\" data-reqmsg=\"Name cannot be blank.\" data-invmsg=\"Name is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \/>\n    \n    \n<\/div>\n<div id=\"frm_field_109_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n    <label for=\"field_u79jj\" class=\"frm_primary_label\">Email Address\n        <span class=\"frm_required\">*<\/span>\n    <\/label>\n    <input type=\"email\" id=\"field_u79jj\" name=\"item_meta[109]\" value=\"\"  data-sectionid=\"106\" style=\"width:300px\" data-reqmsg=\"Email Address cannot be blank.\" data-invmsg=\"Email Address is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \/>\n    \n    \n<\/div>\n<div id=\"frm_field_110_container\" class=\"frm_form_field form-field  frm_top_container\">\n    <label for=\"field_un662\" class=\"frm_primary_label\">General Location\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    \t\t<select name=\"item_meta[110]\" id=\"field_un662\"  data-frmval=\"Please Select\" data-invmsg=\"General Location is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\">Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option><option  value=\"Please Select\" selected='selected'>Please Select<\/option>\t<\/select>\n\t\n    \n    \n<\/div>\n<\/div>\n<div id=\"frm_field_115_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\">Details about your experience<\/h3>\n\n\n<div id=\"frm_field_111_container\" class=\"frm_form_field form-field  frm_top_container\">\n    <label for=\"field_d2k75\" class=\"frm_primary_label\">What happened - brief summary of your medical error experience\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    <textarea name=\"item_meta[111]\" id=\"field_d2k75\" rows=\"5\"  data-sectionid=\"115\" style=\"width:500px\" cols=\"55\" data-invmsg=\"What happened - brief summary of your medical error experience is invalid\" class=\"auto_width\" aria-invalid=\"false\"  ><\/textarea>\n    \n    \n<\/div>\n<div id=\"frm_field_112_container\" class=\"frm_form_field form-field  frm_top_container\">\n    <label for=\"field_ghp16\" class=\"frm_primary_label\">Your current situation (brief summary of your current situation)\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    <textarea name=\"item_meta[112]\" id=\"field_ghp16\" rows=\"5\"  data-sectionid=\"115\" style=\"width:500px\" cols=\"55\" data-invmsg=\"Your current situation (brief summary of your current situation) is invalid\" class=\"auto_width\" aria-invalid=\"false\"  ><\/textarea>\n    \n    \n<\/div>\n<\/div>\n<div id=\"frm_field_121_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\">Please help us eliminate spam . . .<\/h3>\n\n\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<div id=\"frm_field_cptch_number_container\" class=\"form-field frm_top_container auto_width\"><label class=\"frm_primary_label\">Please help us eliminate spam <span class=\"frm_required\">*<\/span><\/label><span class=\"cptch_wrap cptch_math_actions\">\r\n\t\t\t\t<label class=\"cptch_label\" for=\"cptch_input_82\"><span class=\"cptch_span\">7<\/span>\r\n\t\t\t\t\t<span class=\"cptch_span\">&nbsp;&#43;&nbsp;<\/span>\r\n\t\t\t\t\t<span class=\"cptch_span\"><input id=\"cptch_input_82\" class=\"cptch_input \" type=\"text\" autocomplete=\"off\" name=\"cptch_number\" value=\"\" maxlength=\"2\" size=\"2\" aria-required=\"true\" required=\"required\" style=\"margin-bottom:0;display:inline;font-size: 12px;width: 40px;\" \/><\/span>\r\n\t\t\t\t\t<span class=\"cptch_span\">&nbsp;=&nbsp;<\/span>\r\n\t\t\t\t\t<span class=\"cptch_span\">11<\/span>\r\n\t\t\t\t\t<input type=\"hidden\" name=\"cptch_result\" value=\"oIc=\" \/><input type=\"hidden\" name=\"cptch_time\" value=\"1777706521\" \/>\r\n\t\t\t\t\t<input type=\"hidden\" name=\"cptch_form\" value=\"general\" \/>\r\n\t\t\t\t<\/label><span class=\"cptch_reload_button_wrap hide-if-no-js\">\r\n\t\t\t\t\t<noscript>\r\n\t\t\t\t\t\t<style type=\"text\/css\">\r\n\t\t\t\t\t\t\t.hide-if-no-js {\r\n\t\t\t\t\t\t\t\tdisplay: none !important;\r\n\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t<\/style>\r\n\t\t\t\t\t<\/noscript>\r\n\t\t\t\t\t<span class=\"cptch_reload_button dashicons dashicons-update\"><\/span>\r\n\t\t\t\t<\/span><\/span><\/div><div class=\"frm_submit\">\n\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\n\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"166\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n<\/div>\n<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Recipient Application: &nbsp;&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-702","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.3 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Recipient Application - R. 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